Inquest hears of ‘significant changes’ after teenager’s suicide at mental health unit in Bury St Edmunds

Wedgwood House, in Bury St Edmunds
Wedgwood House, in Bury St Edmunds

A mother whose 19-year-old son committed suicide at a mental health unit says she is ‘disappointed risks were known but not acted upon’ but hopes changes made since his death will prevent similar tragedies.

Joe Ruler was found hanging in a room at the Southgate Ward of Wedgwood House, in Bury St Edmunds, on August 29 2010. An inquest into his death heard that ligature risks had been known about for several years before his death.

The incident led to internal and external reviews with ‘significant’ changes and investment by the Norfolk and Suffolk NHS Foundation Trust, which runs the unit. At the time it came under the Suffolk Mental Health Partnership NHS Trust. These include anti-ligature door handles fitted across the trust’s accommodation, ligature risk fittings eliminated in bedrooms, ensuites and communal areas and investment in staff and recruitment.

The inquest heard that Joe’s death was the ‘catalyst’ to broader changes such as improving the care for those with personality disorders in the community.

Mr Ruler, of City View, Canterbury, was admitted to the unit’s Northgate ward on Aug 5 and transferred to Southgate on Aug 14 before being discharged on Aug 25. He was readmitted after walking on the roof of a building in Bury with the intent of jumping off. He reportedly tried to hang himself in a separate incident.

In a report read by Suffolk Coroner Dr Peter Dean, his mother Dawn Brazier said as a little boy he was ‘very happy’ but there were ‘some difficulties in the family context in which he grew up and problems that developed through his life’. He also took drugs.

When he was admitted to Wedgwood, he experienced auditory hallucinations.

The inquest heard he suffered from a form of personality disorder. Dr Christopher Mayer, a consultant in adult psychology, told the hearing that caution must be exercised in making a diagnosis of a personality disorder in someone of Joe’s age and post traumatic stress disorder ‘better describes the nature of his problem’. He said there would now be a ‘much better developed way’ of supporting such a person within the community.

Dr Dean recorded a verdict that Mr Ruler took his own life.

After the inquest, Ms Brazier said: “While I’m disappointed risks were known but not acted upon, I feel reassured that Joe’s death has sparked operational and systematic changes which I hope will prevent similar tragedies from occuring in the future.”

Deborah White, Trust director of operations, said she accepted the verdict and the results of the internal and external investigations. She said: “We’ve already implemented every single one of the reports’ recommendations and all have now been completed. The coronor has acknowledged the commitment of our senior management to continue improvements and I will ensure the lessons of this tragedy are never forgotten.”